Pre anesthesia optimization

Dr mabry

Transcript

1. Pre-Anesthesia Assessment and Medical Evaluation Christian Mabry, MD Medical Director, NYU Center for Preoperative Care Dept. of Anesthesiology NYU Langone Health 8/5/2020
2. Choosing Wisely http://www.choosingwisely.org/societies/society-of-general- internal-medicine/ The mission of Choosing Wisely is to promote conversations between clinicians and patients by helping patients choose care that is: -Supported by evidence -Not duplicates of other tests or procedures already received -Free from harm -Truly necessary Beginning in 2012, national organizations representing medical specialists asked their members to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. There are over 70,000 ICD-10 procedure codes and over 69,000 ICD-10 diagnosis codes.
3. American College of Cardiology Don’t perform routine electrocardiography (ECG) screening as part of pre- operative or pre-procedural evaluations for asymptomatic patients with low perioperative risk of death or myocardial infarction. Even for CAD patients, ECG is mainly for baseline comparison in OR but won’t predict complications. American Society of Anesthesiologists Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g: CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery. The Society of Thoracic Surgeons Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery. American Society of Echocardiography Avoid echocardiograms for preoperative/perioperative assessment of patients with no history or symptoms of heart disease.
4. ERAS Enhanced Recovery after Surgery Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients.
5. ERAS for Radical Cystectomy + Neobladder
6. NYU Protocols – ERAS (Bariatrics)
7. NYU Protocols – ERAS (Bariatrics)
8. NYU Protocols – ERAS (Colon Sx)
9. Wischmeyer P, et al. Anesth Analg, 2018
13. 1. Horlocher TT et al. Reg Anesth Pain Med 2018;43: 263–309 2. Leffert L et al. Anesth Analg 2018;126:928–44 3. Medicine ASoRAaP. ASRA Coags. 2015. Available at: https://itunes.apple.com/us/app/asra-coags/id858796572?mt=8
15. NSQIP American College of Surgeons National Surgical Quality Improvement Program
16. Revised Cardiac Risk Index (RCRI) to estimate % chance of Major Adverse Cardiac Events (MACE)
17. Fleisher LA, Beckman JA, Brown KA, et al: ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
18. What We Want -Information (Full H&P, PMHx, Meds, Allergies, etc…) -Your assessment on optimization -Your assessment on MACE -Acknowledgement that this is a pre-anesthesia visit
19. What We Don’t Want -A “clearance” only note -Limitations on type of anesthesia -Vague recommendations like “control BP,” “keep euvolemic” -Vague information (“pt has COPD, could benefit from pulmonary evaluation eventually,” “patient probably doesn’t have significant coronary disease”)
28. -1 0 1 2 3 4 5 6 Hemoglobin (gm/dL) Improvement after Preoperative Iron Infusions PreOp Anemia Patients
29. Clinical Response to COVID Preop Optimization Clinic Response to COVID
30. “What’s the first question an anesthesiologist asks in a job interview??”